CASE B: AORTIC STENOSIS

Presented by: Arwa Al-Onayzan.Group: 6Serial number: 66.

OUR CASE A 85 yo female, have edema, tired, has dyspnea at rest. She has angina and almost faints (no full collapse). Medical history: no cardiac disease. Physical examination: BP= 145/85 mmHg, weak pulse, HR= 66/min. Thrill over carotid artery. Second heart sound is feeble, loud systolic murmur in right 2 intercostal space. Normal lung with no edema.

QUESTION How can these observations be explained? Which additional examinations would you suggest and why?

INTRODUCTION What is aortic stenosis?? Is inability of aortic valve to open during systole. Etiology?? Senile aortic stenosis (calcification). Rheumatic fever (fibrosis). Hyperlipidemia (deposition of fat).

HOW CAN THESE OBSERVATIONS BE EXPLAINED?

HOW CAN THESE OBSERVATIONS BE EXPLAINED?Observation in

the case Explanation

• She is complaining of edema.

• 70% of blood is in the vein.• Pressure inside heart increase because of

stenosis.• Blood in vein can’t enter heart high hydrostatic

pressure edema.• She is tired, has

dyspnea at rest, has angina and almost faint

• Blood in left side can’t goes out because aortic stenosis.

• Leading to severe low cardiac output.• Low blood (low O2) dyspnea, low blood to muscle

tired.• Low blood to heart angina, low blood to brain

faint.

CON…Observation in

the case Explanation

• Increase BP= 145/85 mmHg

• Blood can’t goes out from the narrowed valve.• Leading to increase BP to pump blood out.

• Her pulse is weak with HR= 66 beat/min

• Blood in left side can’t goes out because aortic stenosis.

• Leading to low cardiac output weak pulse and HR.

• Thrill over the carotid arteries, loud systolic murmur in 2nd (IC)

• Blood can’t goes out from the narrowed valve during systole.

• Creating abnormal sound (ESM).• And thrill over the carotid.

QUIZ TIME!

Q1) give me 2 symptoms of aortic valve stenosis?

WHICH ADDITIONAL EXAMINATIONS WOULD YOU

SUGGEST AND WHY?

DIAGNOSIS OF AORTIC STENOSIS

To make diagnosis we need:1. Medical history.2. Physical examination.3. Investigation. Physical examination:• Auscultation of the heart. Murmur of aortic stenosis is a high-pitched, "diamond shaped" crescendo-decrescendo, midsystolic ejection murmur. Heard best at the 2end right upper sternal border radiating to the neck and carotid arteries.

INVESTIGATION Echocardiogram:• It uses sound waves to produce an image of the heart. • This is the primary test to diagnosis AS.• Evaluate the severity. Electrocardiogram (ECG):• Record action potential in the heart.• Left ventricular hypertrophy.

CON… Chest X-ray:• Shows LVH.• Reveal calcium deposits on the aortic valve.• Check the lungs (lung congestion) Cardiac catheterization:• Uses tube or catheter and insert it to artery.• Inject dye to artery and use X-ray to reveal it.• show any blockages in arteries can coexist with aortic valve stenosis that may need surgical treatment along with aortic valve stenosis.

CON… Exercise tests:• Done to asymptomatic patients.• To evaluate how the heart responds to exercise.• And to measure your tolerance for activity. Computerized tomography (CT) scan:• Measure the size of the aorta and look at aortic valve.• May inject a dye into blood vessels to show the blood flow (CT angiography).

CON… Magnetic resonance imaging (MRI):• Uses powerful magnets and radio waves to create detailed images of heart and heart valves. • May inject a dye into your blood vessels to highlight the heart and blood vessels in images (magnetic resonance angiography).• Uses to measure the size of the aorta. B-type Natriuretic Peptide:• It provide incremental prognostic information in predicting symptom onset in asymptomatic patients with severe aortic stenosis.

LAP TEST Serum electrolyte levels. Cardiac biomarkers. Complete blood count. Arterial blood gas.

QUIZ TIME! Q1) give 2 example of investigation of the AS??

SUMMARY

Aortic steno

sis

Explanation of

observations

Investigation

DefinitionCauses

General mechanis

ms

ANY QUESTION?

REFERENCE Merk Manual (19 Edition), (Page 2200-2203). Kumar & Clark’s Clinical Medicine Book (Ninth Edition), (Page 1049- 1050). Aortic Stenosis Workup. MD, E. S. (2016, Dec. & jan.), from http://emedicine.medscape.com/article/150638-overview.